Common use of Fraud and Abuse Program Clause in Contracts

Fraud and Abuse Program. The Contractor shall have internal controls, policies and procedures, and a compliance plan to guard against fraud and abuse. Specifically, the Contractor shall have written policies, procedures, and standards of conduct that articulate the Contractor’s commitment to comply with all applicable federal and state standards subject to approval by the Division. At a minimum, the plan shall include the following: a. The designation of a compliance officer and a compliance committee that is accountable to senior management. b. Effective training and education for the compliance officer and the Contractor’s employees. c. Effective lines of communication between the compliance officer and the Contractor’s employees. d. Enforcement of standards through well publicized disciplinary guidelines. e. Provision for internal monitoring and auditing. f. Provision for prompt response to detected offenses and for development of corrective action initiatives relating to this Contract. The Contractor shall report Enrollee or provider fraud or abuse which it had reasonable cause to suspect, or should have had reasonable cause to suspect, immediately to the Division, and shall cooperate with the Division regarding the investigation. Failure to do so could result in criminal and/or civil penalties. a. The information to be reported on providers must include the provider name, address, provider number, phone number; the name, title, address, agency and phone number of the person making the report; and details of the report such as information source, names, and list of attached documentation. b. The information to be reported regarding Enrollees must include the Enrollee's name, address, Medicaid identification number; the name, title, address, agency and phone number of the person making the report; and details of the report. c. Quarterly the Contractor must report the number of complaints of fraud and abuse made to the Division that warrant preliminary investigation and the following is to be reported for each case of suspected fraud and abuse that warrants a full investigation: provider name and number, source of complaint, type of provider, nature of complaint, approximate range of dollars involved, and the legal/administrative disposition of the case.

Fraud and Abuse Program. The Contractor shall have internal controls, policies and procedures, and a compliance plan to guard against fraud and abuse. Specifically, the Contractor shall have written policies, procedures, and standards of conduct that articulate the Contractor’s commitment to comply with all applicable federal and state standards subject to approval by the Division. At a minimum, minimum the plan shall include the following: a. The designation of a compliance officer and a compliance committee that is are accountable to senior management.; b. Effective training and education for the compliance officer and the Contractor’s employees.; c. Effective lines of communication between the compliance officer and the Contractor’s employees.; d. Enforcement of standards through well publicized disciplinary guidelines.; e. Provision for internal monitoring and auditing.; f. Provision for prompt response to detected offenses and for development of corrective action initiatives relating to this Contract. The Contractor shall report Enrollee or provider fraud or abuse which it had reasonable cause to suspect, or should have had reasonable cause to suspect, immediately to the Division, and shall cooperate with the Division regarding the investigation. Failure to do so could result in criminal and/or civil penalties. a. The information to be reported on providers must include the provider name, address, provider number, phone number; the name, title, address, agency and phone number of the person making the report; and details of the report such as information source, names, and list of attached documentation. b. The information to be reported regarding Enrollees must include the Enrollee's name, address, Medicaid identification number; the name, title, address, agency and phone number of the person making the report; and details of the report. c. Quarterly the Contractor must report the number of complaints of fraud and abuse made to the Division that warrant preliminary investigation and the following is to be reported for each case of suspected fraud and abuse that warrants a full investigation: provider name and number, source of complaint, type of provider, nature of complaint, approximate range of dollars involved, and the legal/administrative disposition of the case.